A prospective randomized trial of Tannenbaum-type Teflon-coated stents versus polyethylene stents for distal malignant biliary obstruction

New anti-reflux plastic stent to reduce the risk of stent-related cholangitis in the treatment of biliary strictures

BACKGROUND

There is little data available on the role of new anti-reflux plastic stents (ARPSs).

AIM

To compare the use of ARPSs with that of traditional plastic stents (TPSs) for patients with biliary strictures.

METHODS

Consecutive patients with biliary strictures who underwent first endoscopic biliary stenting between February 2016 and May 2019 were included. The onset of stent-related cholangitis, stent patency, clinical success, and other adverse events were evaluated.

RESULTS

Sixty-seven patients in the ARPS group and 66 patients in the TPS group were included in the final analyses. Fewer patients experienced stent-related cholangitis in the ARPS group than that in the TPS group (8 patients vs 18 patients; P = 0.030). The median time till the onset of first stent-related cholangitis was later in the ARPS group than that in the TPS group (128.5 d vs 76 d; P = 0.039). The cumulative median stent patency in the ARPS group was 185 d, which was significantly longer than that in the TPS group (133 d; P = 0.001). The clinical success rates and other adverse events did not significantly differ between both groups.

CONCLUSION

Placement of new ARPS might be a safe and effective optional therapeutic strategy to reduce the risk of stent-related cholangitis and prolong stent patency.

Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.

Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); 2 antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); 3 bile duct cannulation rate (key performance measure, at least 90%); 4 tissue sampling during EUS (key performance measure, at least 85%); 5 appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); 6 bile duct stone extraction (key performance measure, at least 90%); 7 post-ERCP pancreatitis (key performance measure, less than 10%); and 8 adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues.

Preliminary clinical application of integrated 125I seeds stents in the therapy of malignant lower biliary tract obstruction

PURPOSE

To evaluate the clinical efficacy of percutaneous trans-hepatic integrated 125I seed stents implantation for malignant lower biliary tract obstruction.

METHODS

Thirty-two patients with malignant lower biliary obstruction were randomly divided into two groups. One group underwent the therapy with integrated 125I seed stents (Test group, n = 13), and another group received conventional metal stents implantation for treatment (Control group, n = 19). The pre- and post-operative changes in biochemical indices, white blood cell count, IgG level, stent patency, survival time, tumor size and complications were compared between the two groups. RECIST 1.1 (Response Evaluation Criteria In Solid Tumors) was used to evaluate therapeutic effects. The average follow-up time was 12.3 months.

RESULTS

The differences between pre- and post-operative (30 days) intragroup biochemical indices had statistically significant difference (P < 0.05), but there were no significant differences (P > 0.05) in leukocyte counts and IgG levels. As to the median time of stent patency and patients' survival, there were significant differences (P < 0.05) between Control and Test groups (3.9 months vs. 8.1 months, 139 days vs. 298 days, respectively). Three months after the operation, the average tumor size was reduced in the Test group, but was increased in the Control group (P < 0.05). There was no significant difference in the incidence of complications between the two groups. The evaluation results using RECIST 1.1 showed that there were statistically significant differences between the two groups in terms of the rates of remission, control, and progression (χ2 = 17.5, P < 0.05).

CONCLUSIONS

The study indicates that integrated 125I seed stents are effective in reducing jaundice symptoms, inhibiting tumor growth, improving stent patency and prolonging patient survival, which may serve as a safer and more feasible method in treating malignant lower biliary obstruction with minimal invasiveness.

How are palliative care cancer populations characterized in randomized controlled trials? A literature review

CONTEXT

The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research.

OBJECTIVES

To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs).

METHODS

The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles.

RESULTS

The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported.

CONCLUSION

A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.

Pancreatic and biliary stents

Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.

Optimizing biliary stent patency by coating with hydrophobin alone or hydrophobin and antibiotics or heparin: an in vitro proof of principle study

PURPOSE

Although a wide range of biliary plastic and metal stents is on offer nowadays, the ideal cost-effective stent that functions permanently and that is easy to handle regarding its exchange is still not available. Therefore we tested in an in vitro model if the coating of plastic stents with hydrophobin alone or with hydrophobin and antibiotics or heparin in combination leads to an inhibition of the clogging process.

METHODS

We coated commercially available biliary plastic stents with hydrophobin alone, as well as with hydrophobin and antibiotics or heparin in combination. After an incubation period of 28 days in human bile, we examined the stents by scanning electron microscopy to see whether the clogging material on its surface was reduced.

RESULTS

Coating of plastic stents with hydrophobin led to a reduction in the amount of adherent material on the surface of the stents. Coupling of ampicillin/sulbactam or levofloxacin did not lead to a further reduction of the clogging material, whereas coupling with highly concentrated heparin did reduce the adherent material.

CONCLUSIONS

The coating of biliary plastic stents with hydrophobin or with hydrophobin and heparin in combination seems to be a promising option to delay the clogging process.

Endoscopic management of benign biliary strictures

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.

A comparative evaluation of early stent occlusion among biliary conventional versus wing stents

BACKGROUND AND STUDY AIMS

Conventional plastic stents with a lumen typically have limited patency. The lumenless wing stent was engineered to overcome this problem. The objective of this study was to compare the incidence of early stent occlusion (symptomatic occlusion/cholangitis necessitating re-insertion within 90 days) for wing stents and conventional plastic stents.

PATIENTS AND METHODS

Patients with biliary pathology treated with plastic biliary stenting during the period 2003-2009 comprised the study cohort. Patients who had at least one biliary wing stent placed comprised the wing stent group, whereas patients who underwent only conventional stent plastic placement comprised the conventional stent group. Patients were stratified by indication: benign biliary strictures (group 1), malignant biliary strictures (group 2), or benign biliary non-stricture pathology (group 3). The association of stent type with the occurrence of primary outcome by indication was analyzed by use of multivariable logistic regression.

RESULTS

Three-hundred and forty-six patients underwent 612 ERCP procedures with placement of plastic biliary stent(s). On multivariate analysis, early stent occlusion did not differ between the wing and conventional groups in groups 1, 2, and 3. Among patients who achieved primary outcome in group 2, significantly fewer patients in the wing group had cholangitis (6.7% vs. 39.1%, P = 0.03). Among patients who achieved primary outcome in group 3, significantly fewer patients in the wing group had cholangitis (10% vs. 50%, P = 0.03).

CONCLUSIONS

Early stent occlusion was similar for wing stents and conventional plastic stents. Wing stents, however, were associated with a lower incidence of cholangitis in patients with malignant biliary obstruction and benign non-stricturing biliary pathology.

New 10F soft and pliable polyurethane stents decrease the migration rate compared with conventional 10F polyethylene stents in hilar biliary obstruction: results of a pilot study

BACKGROUND

Migration of biliary stents is a well-documented problem that can result in a variety of complications. The newly designed polyurethane (PU) stent, which is made of a soft and pliable material, may prevent distal and proximal stent migration.

OBJECTIVE

To compare the migration rate of the PU stent with that of the conventional polyethylene stent (PE).

DESIGN

Prospective, comparative, randomized trial.

SETTING

Tertiary academic medical centers.

PATIENTS

Fifty patients with a hilar stricture who had not undergone a previous drainage procedure.

INTERVENTION

In patients with hilar stricture, random assignment of either a PU stent or PE stent.

MAIN OUTCOME MEASUREMENT

The rate of early proximal or distal migration before stent occlusion.

RESULTS

Overall and distal migration rates were significantly lower in the PU group than in the PE group (4.5% vs 29%, P = .032 and 4.5% vs 26.1%, P = .049, respectively). There was no significant difference between the migration rate in benign and malignant biliary strictures (5.9% vs 21.4%, P = .167). Sex, stent length, preprocedure bilirubin level, and Bismuth type were not associated with migration rate in either the PU or PE group. Median stent patency was 148 days (range 36-224 days) in the PU group and 151 days (range 40-241 days) in the PE group (P = .891).

LIMITATIONS

Small sample size.

CONCLUSIONS

Use of the new PU stent, which is soft and pliable, decreased distal migration. The PU stent patency rates appear similar, but this study is not powered to demonstrate equivalency of patency.

Removal of a large stone growing around and encasing a plastic biliary stent: respect the ductal axis

Plastic biliary stents are commonly used during Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The main indication for biliary stenting is benign or malignant obstruction. Plastic stents, among others, can be used as an escape route in patients with large common bile duct stones, or in cases of acute cholangitis with or without sphincterotomy to provide drainage until definitive treatment. Stent occlusion is the main disadvantage, limiting their patency to around 3 months, after which replacement is recommended. We present a case of a large, close to 2cm, stone developing around and encasing the proximal end of a plastic biliary stent. The stent/stone complex was successfully removed en bloc. The stent was placed in the common bile duct without sphincterotomy, and remained in situ for 2 years. The presented case highlights the importance of definitive treatment for common bile duct stones, the need to respect the ductal axis especially when dealing with large stones and the significance of biliary sphincterotomy during endoscopic interventions in the bile duct.

Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas

Together with biliary drainage, which is an appropriate procedure for unresectable biliary cancer, biliary stent placement is used to improve symptoms associated with jaundice. Owing to investigations comparing percutaneous transhepatic biliary drainage (PTBD), surgical drainage, and endoscopic drainage, many types of stents are now available that can be placed endoscopically. The stents used are classified roughly as plastic stents and metal stents. Compared with plastic stents, metal stents are of large diameter, and have long-term patency (although they are expensive). For this reason, the use of metal stents is preferred for patients who are expected to survive for more than 6 months, whereas for patients who are likely to survive for less than 6 months, the use of plastic stents is not considered to be improper. Obstruction in a metal stent is caused by a tumor that grows within the stent through the mesh interstices. To overcome such problems, a covered metal stent was developed, and these stents are now used in patients with malignant distal biliary obstruction. However, this type of stent has been reported to have several shortcomings, such as being associated with the development of acute cholecystitis and stent migration. In spite of these shortcomings, evidence is expected to demonstrate its superiority over other types of stent.

Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas. ACTA ACUST UNITED AC. 2008;15:69-73. [PMID: 18274846 PMCID: PMC2794345 DOI: 10.1007/s00534-007-1282-x]

Together with biliary drainage, which is an appropriate procedure for unresectable biliary cancer, biliary stent placement is used to improve symptoms associated with jaundice. Owing to investigations comparing percutaneous transhepatic biliary drainage (PTBD), surgical drainage, and endoscopic drainage, many types of stents are now available that can be placed endoscopically. The stents used are classified roughly as plastic stents and metal stents. Compared with plastic stents, metal stents are of large diameter, and have long-term patency (although they are expensive). For this reason, the use of metal stents is preferred for patients who are expected to survive for more than 6 months, whereas for patients who are likely to survive for less than 6 months, the use of plastic stents is not considered to be improper. Obstruction in a metal stent is caused by a tumor that grows within the stent through the mesh interstices. To overcome such problems, a covered metal stent was developed, and these stents are now used in patients with malignant distal biliary obstruction. However, this type of stent has been reported to have several shortcomings, such as being associated with the development of acute cholecystitis and stent migration. In spite of these shortcomings, evidence is expected to demonstrate its superiority over other types of stent.

Impact of reducing duodenobiliary reflux on biliary stent patency: an in vitro evaluation and a prospective randomized clinical trial that used a biliary stent with an antireflux valve

BACKGROUND

The mechanisms leading to occlusion of plastic biliary stents (PBS) are not known.

OBJECTIVE

To evaluate the impact of reducing duodenobiliary reflux on stent patency rate.

DESIGN

A newly designed antireflux PBS (AR-PBS) was tested in vitro by using ox bile. A prospective randomized trial in human beings was conducted.

SETTING

Tertiary medical center.

PATIENTS

Patients with malignant bile-duct strictures were studied.

INTERVENTIONS

A PBS or an AR-PBS stent was placed by using standard techniques, and the patients were followed at regular intervals. Patients presenting with stent occlusion underwent re-stent placement with either a PBS or a metal stent.

MAIN OUTCOME MEASUREMENTS

In vitro: resistance to retrograde flow and comparison of the basal and peak antegrade flow pressures between the 2 stents. In vivo: stent patency rates, complications, and the efficacy of the stents in improving the liver test.

RESULTS

The AR-PBS stent could withstand a retrograde pressure gradient of >320 mm Hg compared with <1 mm Hg for the PBS. Secondary to the siphon effect of the valve, the antegrade flow resistance offered by the AR-PBS was on the negative side for all flow rates compared with PBS (P < .001). The median patency of the AR-PBS in human studies was 145 days (range, 52-252 days) compared with 101 days (range, 41-210 days) for the PBS (P = .002). Both stents were equally effective in improving the liver test, and complication rates were similar in the 2 groups.

LIMITATIONS

The occluded stents were not examined microscopically.

CONCLUSIONS

The antireflux biliary stent remains patent for a longer time and hence duodenobiliary reflux may be contributing to stent occlusion.

Malignant distal biliary obstruction: a systematic review and meta-analysis of endoscopic and surgical bypass results. Cancer Treat Rev. 2007;33:213-221. [PMID: 17157990 DOI: 10.1016/j.ctrv.2006.10.006]

BACKGROUND

Surgical bypass and endoscopic stents are available for palliative bypass of malignant distal biliary obstruction.

AIM

Comparison of reported outcomes in randomized controlled trials (RCTs) which included surgery, endoscopic plastic stents or endoscopic metal stents in palliative relief of malignant distal biliary obstruction.

METHODS

Systematic review and meta-analysis of published literature and conference proceedings review to June 2006.

RESULTS

We found 24 studies, containing 2436 patients, which met our inclusion criteria. Endoscopic stenting with plastic stents (three studies) is associated with a lower risk of complications (RR 0.60, 95% CI 0.45-0.81), but a higher risk of recurrent biliary obstruction (RR 18.59, 95% CI 5.33 -64.86) than traditional surgical bypass. Self-expanding metal stents (seven studies) are associated with a significantly reduced risk of recurrent biliary obstruction at 4 months (RR 0.44, 95% CI 0.3, 0.63), or prior to death or end of study (RR 0.52, 95% CI 0.39-0.69), but are not superior to plastic stents in terms of technical success, therapeutic success, mortality or complications. Cost-effectiveness outcomes were not suitable for meta-analysis. No other plastic stent designs have been demonstrated to be superior to polyethylene stents (12 studies).

CONCLUSIONS

Endoscopic metal stents are the intervention of choice in patients with malignant distal biliary obstruction, producing similar outcomes to plastic stents, but with improved patency rates.

Endoscopic biliary drainage for patients with unresectable pancreatic cancer with obstructive jaundice who are to undergo gemcitabine chemotherapy

AIM: To assess optimum endoscopic biliary drainage (EBD) in cases with unresectable pancreatic cancer in the era of gemcitabine (GEM).

METHODS: Thirty patients with unresectable pancreatic cancer, who presented with jaundice and underwent chemotherapy using GEM after EBD were included in this study (GEM group). Fifteen cases with the same clinical manifestation and stage of pancreatic cancer treated with EBD alone were also included as controls. A covered metallic stent (CMS) or a plastic stent (PS) was used for EBD. The mean survival time (MST) in each group, risk factors of survival time, type of stent used and associated survival time, occlusion rate of stent, patency period of stent, and risk factors of stent occlusion were evaluated.

RESULTS: MST in the GEM group was longer than that in the control (9.9 mo vs 6.2 mo). In the GEM group, the survival time was not different between those who underwent metallic stenting and those who underwent plastic stenting. Stent occlusion occurred in 60% of the PS group and 7% of the CMS group. The median stent patency in the PS-GEM group and the CMS-GEM group was 5 mo and 7.5 mo, respectively. Use of a PS was the only risk factor of stent occlusion.

CONCLUSION: A CMS is recommended in cases presenting with jaundice due to unresectable pancreatic cancer, since the use of a CMS makes it possible to continue chemotherapy using GEM without repetition of stent replacement.

Antireflux biliary stents: are they the solution to stent occlusions?

Endoscopic insertion of plastic or metal stents is a well-established treatment for malignant biliary obstruction. The major limitation of this technique is stent occlusion. Duodenobiliary reflux has been considered a key contributor to stent occlusion. The presence of plant fibers in 35% to 60% of occluded stents on confocal laser microscopy has further confirmed the presence of reflux when the stent is placed across the papilla. Antireflux stents address this problem by allowing normal antegrade flow but preventing reflux. Recent studies comparing these antireflux stents with the standard Tannenbaum stents have shown significantly prolonged patency. Although initial results are encouraging, larger randomized trials are required to establish efficacy.

Palliative biliary stents for obstructing pancreatic carcinoma

BACKGROUND

Palliative endoscopic stents or surgical by-pass are often required for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the distal biliary tree. The optimal method of intervention remains unknown.

OBJECTIVES

To compare surgery, metal endoscopic stents and plastic endoscopic stents in the relief of distal biliary obstruction in patients with inoperable pancreatic carcinoma.

SEARCH STRATEGY

We searched the databases of the Cochrane Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CancerLit, Current Concepts Database and BIDS (September 2002 to September 2004). The searches were re-run in December 2005 and we are awaiting further details on two trials. Reference lists of articles and published abstracts from UEGW and DDW were hand-searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and different types of endoscopic plastic and metal stents, used to relieve obstruction of the distal bile duct in patients with inoperable pancreatic carcinoma.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Adverse effects information was collected from the trials.

MAIN RESULTS

Twenty-one trials involving 1,454 people were included. Based on meta-analysis, endoscopic stenting with plastic stents appears to be associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher 30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a difference in technical or therapeutic success. Other outcomes were not suitable for meta-analysis. No trials comparing endoscopic metal stents to surgery were identified. In endoscopic stent comparisons, metal biliary stents appear to have a lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant statistical difference in technical success, therapeutic success, complications or 30-day mortality using meta-analysis. A narrative review of studies of the cost-effectiveness of metal stents drew conflicting conclusions, but results may be dependent on the patients' length of survival.Neither Teflon, hydrourethane, or hydrophilic coating appear to improve the patency of plastic stents above polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to polyethylene stents in one trial. The single eligible trial comparing types of metal stents reported higher patency with covered stents, but also a higher risk of complications. These results are based on review of the trials individual results only.

AUTHORS' CONCLUSIONS

Endoscopic metal stents are the intervention of choice at present in patients with malignant distal obstructive jaundice due to pancreatic carcinoma. In patients with short predicted survival, their patency benefits over plastic stents may not be realised. Further RCTs are needed to determine the optimal stent type for these patients.

Endoscopic approaches for palliation of luminal gastrointestinal obstruction

Much of the workload of a typical gastroenterologist is devoted to screening patients for gastrointestinal malignancies. Efforts such as colorectal cancer screening via colonoscopy and endoscopic surveillance of patients with Barrett's esophagus are widespread and widely endorsed. In recent years, the armamentarium of endoscopy has broadened considerably and now affords physicians a variety of nonsurgical means to palliate malignant obstruction of the gastrointestinal tract. This article reviews endoscopic techniques to treat malignant esophageal, biliary, small bowel, and colonic obstruction.

Palliative biliary stents for obstructing pancreatic carcinoma

BACKGROUND

Palliative endoscopic stents or surgical by-pass are often required for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the distal biliary tree. The optimal method of intervention remains unknown.

OBJECTIVES

To compare surgery, metal endoscopic stents and plastic endoscopic stents in the relief of distal biliary obstruction in patients with inoperable pancreatic carcinoma.

SEARCH STRATEGY

We searched the databases of the Cochrane Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane Central Register of Controlled Trials , MEDLINE, EMBASE, CancerLit, Current Concepts Database and BIDS (September 2002 to September 2004). Reference lists of articles and published abstracts from UEGW and DDW were hand-searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and different types of endoscopic plastic and metal stents, used to relieve obstruction of the distal bile duct in patients with inoperable pancreatic carcinoma.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Adverse effects information was collected from the trials.

MAIN RESULTS

Twenty-one trials involving 1,454 people were included. Based on meta-analysis, endoscopic stenting with plastic stents appears to be associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher 30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a difference in technical or therapeutic success. Other outcomes were not suitable for meta-analysis. No trials comparing endoscopic metal stents to surgery were identified. In endoscopic stent comparisons, metal biliary stents appear to have a lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant statistical difference in technical success, therapeutic success, complications or 30-day mortality using meta-analysis. A narrative review of studies of the cost-effectiveness of metal stents drew conflicting conclusions, but results may be dependent on the patients' length of survival. Neither Teflon, hydrourethane, or hydrophilic coating appear to improve the patency of plastic stents above polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to polyethylene stents in one trial. The single eligible trial comparing types of metal stents reported higher patency with covered stents, but also a higher risk of complications. These results are based on review of the trials individual results only.

AUTHORS' CONCLUSIONS

Endoscopic metal stents are the intervention of choice at present in patients with malignant distal obstructive jaundice due to pancreatic carcinoma. In patients with short predicted survival, their patency benefits over plastic stents may not be realised. Further RCTs are needed to determine the optimal stent type for these patients.

Endoscopic palliation of pancreaticobiliary malignancies

The palliation of pancreaticobiliary malignancies has changed over the last two decades. With the development of biliary stents, minimally invasive procedures have replaced surgical techniques. Endoscopically placed stents remain the mainstay for the palliative treatment of malignant biliary obstruction from unresectable pancreaticobiliary tumors. Further improvements in stent designs and advances in other endoscopic technologies are expected, and these should expand the role of minimally invasive palliation. This article reviews the current and anticipated roles of endoscopic techniques in the palliation of pancreaticobiliary malignancies.

Endobiliary stents for palliation in patients with malignant obstructive jaundice

BACKGROUND

Endobiliary drainage for malignant obstructive jaundice presents a viable palliative alternative. Its role and efficacy depend on factors related to the stent, procedure, and patient.

GOALS

To review the evidence in the literature in which settings plastic or metal stents are cost-effective, and whether adjuvant measures or patient-related factors affect duration of stent patency.

STUDY

Using databases a literature search was performed for papers published from 1979 to April 2004. All retrieved papers reporting experimental or clinical observations were rated according to strength of evidence, and carefully analyzed.

RESULTS AND CONCLUSIONS

Metal stents (Wallstent) stay patent longer than plastic stents (large-bore polyethylene with side-holes), overall median 250 and 110 days, respectively, and seem cost-effective in patients with longer than about 6 months survival, which cannot be accurately predicted. Antibiotics or choleretic agents do not prolong stent patency in clinical settings. In case of stent occlusion, indicated stent exchanges and insertion of a plastic stent, respectively, seem cost-effective in patients initially treated with plastic and metal stents.